.06 Protocols.

A. The medical director and director of nurse midwifery shall develop protocols for the management of routine and emergency care of the patient and her fetus or newborn during pregnancy, birth, and postpartum through discharge, whether through completion of the pregnancy or referral or transfer to other levels of care. Theprotocols shall include procedures for the:

(1) Transfer of patients or newborns for appropriate hospital obstetric and newborn care; and

(2) Use of ultrasound imaging that is:

(a) Consistent with the current standards of care; and

(b) Within the scope of practice for a:

(i) Physician; or

(ii) Certified nurse midwife.

B. The administrator shall:

(1) Ensure that all protocols are fully implemented;

(2) Periodically review the protocols and revise them when necessary; and

(3) Make the protocols available to staff for reference on site at all times.